Education is a core mission of medical schools in the United States. Schools have varied in their investment in and commitment to continuing medical education (CME) and professional development. Some focus primarily on internal faculty development and performance improvement, while others focus more on meeting the learning needs of alumni and external audiences.
The Accreditation Council for Continuing Medical Education (ACCME) was founded in 1981 as an independent nonprofit organization to ensure that educational programming provides safe spaces for clinicians to learn.1 With its staff and volunteers, the ACCME sets standards for education to ensure accredited CME can be trusted by learners. Accredited organizations must demonstrate that their education is balanced, evidence-based, designed to meet real needs, and evaluated appropriately.1
Each year since 1998, accredited organizations within the ACCME system have been required to submit data describing their CME activities. From these data and information, the ACCME has produced publicly available annual reports as a service to accredited CME organizations and other stakeholders.2 Our purpose is to provide a long-term overview of CME at ACCME-accredited medical schools in the United States. We also compare CME activities between medical schools and other ACCME-accredited organizations.
We define a CME activity as an educational offering that was planned, implemented, and evaluated in accordance with the ACCME Accreditation Criteria, Standards for Commercial Support, and policies. A glossary including the definitions and examples used in preparing the annual reports and this report is available in Supplemental Digital Appendix 1 (available at https://links.lww.com/ACADMED/A764). Data were gathered from the annual ACCME reports (available at www.accme.org), for the time period between their original year of publication (1998) and 2017.2
CME activities that were presented by organizations accredited in the ACCME system offered American Medical Association Physician’s Recognition Award (AMA PRA) Category 1 credit. All ACCME-accredited organizations were required to self-report and submit the following CME data: activity types, hours of instruction, physician learner interactions, and other learner interactions (formerly known as nonphysician participants). ACCME-accredited organizations report the number of learners at each activity. These are referred to as interactions. The data represent aggregate numbers of interactions and not the number of unique learners. Reported income was generated from 3 primary sources: combined registration fees, government grants, private donations, and allocations from a CME office’s parent organization or other internal departments; commercial support; and advertising/exhibits.
In 2010, the ACCME began to collect the annual data through an online database known as the Program and Activity Reporting System.3 This web-based portal was designed to centralize and streamline the collection, management, and analysis of detailed program and activity data from all accredited CME organizations. Over the years, changes in reporting definitions were made to enhance the standardization of the data collected. For example, in 2004, the ACCME reviewed and recategorized some of the organizational types, for consistency and accuracy. In 2011, the ACCME eliminated the need for accredited organizations to estimate and report the dollar value of in-kind commercial support; instead, organizations were asked to report the nature of the in-kind support. Through 2014, accredited organizations aggregated and reported income from registration fees, government grants, private donations, and allocations from a CME office’s parent organization or other internal departments. This was called “other income.” Beginning in 2015, accredited organizations were instructed to report this income by category, instead of aggregating it; in addition, they were no longer required to report internal allocations. Beginning with the 2016 ACCME Annual Report, accredited organizations were instructed to include residents and fellows as physicians rather than as other learners. Nonphysician health care professionals (e.g., nurses, physician assistants, nurse practitioners, pharmacists, social workers, counselors) were grouped as other learners and not identified separately.
We compared the CME activities in the ACCME’s dataset during the same year between medical schools and the combination of all other ACCME-accredited organizations (nonprofit physician membership organizations, nonprofit organizations such as foundations and charities, government or military, publishing/education companies, hospital/health care delivery systems, insurance companies/managed-care organizations, others that did not easily fit into the other categories). This study does not include activities offered by organizations accredited by one of the state medical society accreditors. Our investigation was determined to be exempt from review by the University of New Mexico Human Research and Review Committee, since it did not involve human research.
The number of medical schools accredited by the ACCME grew from 115 in 1998 to 131 in 2017. Table 1 displays the number of accredited organizations for each organization type. The proportion of medical schools in relation to all other ACCME-accredited organizations did not change between 1998 (18.2% of all 632 organizations) and 2017 (19.0% of all 688 organizations). Other common ACCME-accredited organizations were physician membership organizations (35.4% in 2017), which saw similar growth to medical schools, and publishing/education companies (19.0% in 2017), which saw the greatest growth. The category “other” showed a substantial drop from 114 (18.0% of all 632 organizations) in 1998 to 29 (4.2% of all 688 organizations) in 2007, largely due to more precise categorization.
The total number of accredited CME activities delivered by medical schools in the United States rose from 21,513 out of a total of 48,092 (44.7%) in 1998 to a peak of 36,695 out of a total of 100,935 (36.4%) in 2008. Thereafter, the total number of activities remained quite stable (mean, 27,687 per year) despite the addition of 8 additional medical schools to the cohort. The mean number of total annual activities per medical school (214) remained higher than in all other organization categories (175).
Courses and regularly scheduled series (RSS) were the most common of all activity types produced by medical schools from 1998 to 2017 (39% and 29%, respectively) and remained constant for medical schools. Internet enduring materials, and learner participation in them, grew between 2003 and 2009 before declining. Other educational activities that were least reported during this 20-year period consisted of live Internet presentations, committee learning, Internet searching and learning, journal-based CME, and learning from teaching (these include self-directed learning overseen by an accredited organization). In contrast to medical schools, other ACCME-accredited organizations reported a fourfold growth in total annual activities (from approximately 26,000 to 97,000 activities per year between 1998 and 2017), mostly due to increases in numbers of courses and enduring Internet offerings.
Each year, medical schools offered between 280,000 and 370,000 hours of instruction. The number of instruction hours per averaged activity was consistently higher for RSS than for courses or Internet enduring materials. Instruction hours per averaged activity were also generally higher for medical schools than for other ACCME-accredited organizations: RSS activities (26.3 vs 19.8 hours per activity), courses (9.7 vs 7.2 hours per course), and enduring Internet offerings (1.6 vs 2.1 hours per offering).
The numbers of learner interactions for medical schools are shown in Figure 1 for each type of activity. The number more than doubled from 2,104,162 out of 5,207,365 (40.4% of all activities) in 1998 to 5,075,855 out of 19,289,622 (26.3% of all activities) in 2011 (although the share of all learner interactions decreased) before becoming constant thereafter. This increase in numbers of interactions was primarily due to increases in learner interactions at RSS activities. (Learners attending RSS are reported for each session they attend; therefore, unique learners may be reported multiple times for the same RSS.) As compared with other ACCME-accredited organizations, medical schools interacted more consistently with physicians than with learners from other health professions: in 2017, for medical school CME providers, 3,122,274 out of 4,638,285 learner interactions were with physicians (67.3%) while for non–medical school CME providers, 10,352,119 out of 19,870,062 learner interactions were with physicians (52.1%). Over time, medical schools grew their nonphysician audience to a much lower extent than other types of organizations.
In 2017, each school generated a median of 132 activities (interquartile range [IQR]: 72–268) and a median of 29,824 learner interactions (IQR: 8,464–46,255) annually. The average number of learners at medical school CME activities was highest for RSS activities and fewest for courses. In contrast, for non–medical school providers, Internet enduring materials reported more learner interactions per activity than RSS or courses.
The total income from CME activities at ACCME-accredited medical schools increased between 1998 and 2004, peaked in 2010, and has generally declined since then (see Figure 2). Despite declines in commercial support thereafter, medical schools increased the numbers of activities offered. Income from advertising and exhibits accounted for a small but increasing amount of income for all accredited organizations including medical schools. In 2017, medical schools reported a median annual income of $1.0 million (IQR: $0.2–2.9 million) from their CME activities, comprising approximately 44% from registration fees, 39% from commercial support, and 13% from advertising and exhibits. Income generated by all other ACCME-accredited organizations did not decline but remained stable (see Figure 2), mostly due to increases in revenue generation from proportionally more CME activities.
While medical schools represent less than 20% of all 688 of the organizations the ACCME gives national accreditation to, their role is pivotal and their influence far-reaching. Medical schools have had a tradition of reflecting their commitment to their communities of learners by building robust CME departments.4–6 Though their role in CME was dominant 2 decades ago, medical schools have expanded their activities and their audiences to a more limited extent than other organization types over time. Our data show that medical schools have been dependent on a relatively fixed amount of financial support, which appears to constrain internal capacity to evolve, innovate, and respond to changing learner needs and dynamics. In contrast, the development of resource-intensive modes, such as online learning, has allowed other organization types to generate growth in engagement and use. In particular, our findings suggest that organizations that invested in building online learning experiences and engaged learners from other health professions demonstrated substantial growth and engagement over time. Findings of this study show that nonphysicians are increasingly participating in CME; we expect that future data will support the contention that organizations that build activities designed for and by the interprofessional team also see growth in learner interactions.7
Our findings suggest that medical schools generally continue to rely on standard formats of education, particularly courses and RSS activities, formats that have been dominated by traditional Socratic didactics. Dependence on this model is likely to increasingly constrain the organization’s ability to meet the needs of its changing learners, particularly the digitally savvy generation of health care professionals who generally consider live didactics to be inefficient and of low utility, and thus avoid this format.8 Medical school CME faculty planners and educators can explore ways to leverage their co-location with their learners and evolve their approach to RSS and courses to deliver attractive and powerful learning experiences that meet the needs of their local and visiting community. They can consider implementing faculty development and educational strategy to create a culture of inquiry and curiosity; provide curated longitudinal curricula; use problem-based cases in small groups; and allow substantive time for learners to work in pairs or groups to share, reflect on, and solve problems. Much research demonstrates the educational efficacy of these approaches and the relative ease with which they can be implemented, yet they appear to be offered in the exception rather than routinely by medical schools.9,10
The traditional division of professions within schools has likely constrained the ability of medical schools to more readily deliver interprofessional learning activities to the same extent as other organizations, but this is a self-imposed limitation. The Joint Accreditation for Interprofessional Continuing Education pathway provides a seamless strategy to leverage collaboration between the accreditors and create interprofessional continuing education.
Our data indicate that there are clear and growing opportunities to leverage the trusted status that medical schools hold and evolve into the online learning space too. Advancements in educational technology that build on adult learning (using adaptation, interleaving, repetition, tracking, reminders, etc.) create new opportunities to design even more effective and efficient educational programs and reach a broader audience of health care professionals. While it was beyond the scope of this study to analyze CME activities for each accredited medical school, how much each school prioritizes CME is demonstrably variable.11 Health systems and academic medical centers that establish, resource, and support their CME and continuing professional development offices as interprofessional educational homes appear to thrive and find the resources to support their work.12 Medical schools that use their CME faculty to facilitate the performance improvement of their clinician community can deliver tangible benefits to their affiliated health systems, showing that CME units deserve to be viewed as value centers rather than as profit centers.6,9
Certain limitations with interpreting ACCME data require attention. Our study was an aggregate of self-reported data submitted from individual accredited organizations. The ACCME followed up with individual organizations if there were any outliers or major changes from previous years. Data in annual ACCME reports did not allow direct comparisons between medical schools. Data from the few newly formed medical schools that were not yet accredited by the Liaison Committee on Medical Education were not included in this report, since it takes time to become ACCME-accredited. Before the 2015 ACCME Annual Report, residents and fellows were reported as nonphysicians. Although the data show an increase in participation by nonphysicians, our findings do not specify which activities were designed by and for interprofessional teams. In 2018, the ACCME began collecting data about interprofessional continuing education activities and will be reporting these data in the future. Since the ACCME does not collect data on expenses, income should not be interpreted as representing profit. ACCME-accredited organizations define their own organizational type and choose “other” if they do not fit into one of the choices. This explains some of the decrease in numbers of “other” organizations. A few examples of organizational types that are categorized as “other” are physician groups and universities not associated with medical schools.
At the intersection of undergraduate, graduate, and CME, schools have the capacity to provide continuity along the education and practice continuum, create longitudinal relationships with clinicians, and engage residents and students in learning with their more experienced colleagues. Medical schools can provide emerging clinicians with education about education, giving them guidance they can use throughout their careers about how to take ownership of their lifelong learning agenda, foster their own self-awareness about gaps and areas for practice improvement, and choose CME that will meet their needs. Aspiring clinicians are drawn to the medical profession with curiosity and a love for learning; by investing in CME and faculty development programs, medical schools can help clinicians develop and sustain joy in learning. Faculty development programs integrated with CME can communicate the value of lifelong learning and inspire future generations of teachers, while building enduring and important faculty competencies.
The rewards for building an effective local CME office are real and growing. Medical schools may be able to build their reputation, generate revenue, and advance their mission to educate and have impact with their CME offerings. Furthermore, they can use CME to create effective teams, improve the quality of patient care, improve efficiencies, reduce staff burnout and turnover, and improve satisfaction and retention, while also assisting their community to meet their regulatory requirements for board certification (accredited organizations can directly issue certification points for several boards) and for optimizing reimbursement (CME is recognized by the Centers for Medicare and Medicaid Services as meeting the improvement activity requirements of the quality payment program). However, barriers to implementing these programs include the increasingly anachronistic perception that CME consists mostly of passive learning that is ineffective at driving behavior change and that the main function of CME offices is to “rubber-stamp” applications for credit. As a result, CME offices are often underresourced and underused. Overcoming these barriers requires a shift in perception on the part of medical school leadership. Leaders need to recognize the strategic value of education as a professional development vehicle that can drive change in consort with institutional and community goals, including quality improvement efforts, patient safety projects, and other health system changes. They need to impart this vision throughout the institution and create strategies for breaking down silos between different divisions, elevating CME offices to the role of strategic partners.
The data provide a foundation for understanding the role of medical schools in CME and for generating future research. It is our hope that this report will generate interest in research and scholarship about how high-quality CME offices can help medical schools fulfill their educational mission. ACCME has made its data available for research to facilitate this effort and will continue to expand and share the depth and variety of information available about the dynamics of professional medical education.
Findings from this 20-year exploration of medical schools’ approaches to CME demonstrate the growing numbers of CME activities over time and a continuing balance in need of and use for a wide diversity of educational approaches, live and in person, as well as online. Looking forward to the next 20 years, stakeholders need to drive and support the evolution of medical school CME to meet the challenges of the changing health care environment. For medical schools to fulfill their responsibility as education leaders, they need to prioritize support for CME offices and faculty development to ensure that CME educators can design and implement activities that deliver to the changing needs of health care professionals, are ever more effective, and facilitate the development of competencies and performance that helps deliver more optimal patient outcomes.
The authors wish to thank Tamar Hosansky for editorial support.